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October 1978 



nmu mm mcmiom 

VADM Willard P. Arentzen, MC, USN 

Surgeon Genera! of the Navy 

RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Managing Editor 

Ellen Casselberry 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 

Contributing Editors 
Contributing Editor-in-Chief: CDR E.L. 
Taylor (MC); Aerospace Medicine: 
CAPT M.G. Webb (MC); Dental Corps: 
CAPT R.D. Ulrey (DC); Education: LT 
R.E. Bubb (MSC); Fleet Support: LCDR 
J.D. Schweitzer (MSC); Gastroenterol- 
ogy: CAPT D.O. Castell (MC); Hospital 
Corps: HMCM HA. Olszak; Legal: 
LCDR R.E. Broach (JAGC); Marine 
Corps: CAPT D.R. Hauler (MC); Medi- 
cal Service Corps: CAPT P.D. Nelson 
(MSC); Nephrology: CDR J.D. Wallin 
(MC); Nurse Corps: CAPT P.J. Elsass 
(NC); Occupational Medicine: CDR J.J. 
Betlanca (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Research: 
CAPT J.P. Bloom (MC); Submarine 
Medicine: CAPT J.C. Rivera (MC) 

POLICY: U.S. Navy Medicine is. an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and profession*! information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U^S- Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical. Dental. Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010). 
Washington. D.C. 20372. Telephone; (Area Code 202) 254- 
4253, 254-4316. 254-4214; Autovon 294^253, 294-4316. 294- 
4214, Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 

The issuance of this publication is approved in accordance 
with Department of the Navv Publications and Printing 
Regulations (NAVEXOS P-35). 


Vol. 69, No. 10 
October 1978 

1 From the Surgeon General 

2 Department Rounds 

Field Dentists with the 1st Marine Brigade ... PA Named BU- 
MED Consultant . . . NOTAP Data Analysis Begins 

5 Safety 

6 Notes and Announcements 

8 Features 

The Nurse Practitioner 
LCDR C.H. Ingram, NC, USN 

14 Scholars' Scuttlebutt 

Naval Residencies: Dialogue Continued 

17 NAVMED Newsmakers 

18 Instructions and Directives 

20 Education and Training 

San Diego Courses for DTs Outlined 

22 Dental Information Retrieval System 

Planning for Tomorrow's Needs Today 

23 Professional 

Reducing the Crossmatch Time 
LCDR W.P. Monaghan, MSC, USN 

26 A Behavioral Treatment of Nocturnal Enuresis 
LTM.R. Marcy, MSC, USNR 
LTJ.B. Hopkins. MSC, USNR 
LTM.D. Cunningham, MSC, USNR 


COVER: At NRMC Corpus Christi, LCDR Dove Coltharp (NC) is a 
nurse practitioner: a new breed of nurse the Navy added to its health 
team several years ago. Just how well has the practitioner been ac- 
cepted by coprofessionals — and by patients themselves? For some 
indications, see the article beginning on page 8. 


From the Surqeon General 

SAC X: New Spirit for 
the Days Ahead 

The Surgeon General's Specialty 
Advisory Conference for 1978 has 
recently been concluded. I consider 
that it was a most fruitful and satis- 
factory meeting. 

The details of many of the delib- 
erations of the conference will be 
reported to you in the November 
and December issues of this maga- 
zine. I would like to relate now, 
however, that the tone of the meet- 
ing was positive, forward-looking, 
and in many respects innovative. I 
think that, with justification, the 
pall of "gloom and doom" that we 
have watched fall over the Medical 
Department is being lifted. 

Constraints on resources of all 
kinds persist — but the decrements 
seem stabilized, and the spirit is to 
proceed with the job ahead. 

If we are to accomplish our mis- 
sion properly — that is, to render the 
best health care to our beneficiaries 
at sea and ashore — our system must 
have within it comprehensive train- 
ing programs second to none. To 
this I have pledged my office, and I 

require that this goal be of the high- 
est priority. 

In order that this goal be achieved, 
I ask all of you to join with me and 
the dedicated attendees of SAC X. 
Join us in continued loyalty and ser- 
vice to the Medical Department. 
Continue your roles as teachers, 
managers, and health-care pro- 
viders, operationally as well as clini- 

We require the continued benefit 
of your talents and experience to 
succeed. Help me implement the 
spirit of SAC X. 

J/fr, / U^^-^^y^^Z^-- 


Vice Admiral, Medical Corps 
United States Navy 

Volume 69, October 1978 

Department Rounds 

Field Dentists with the 1st Marine Brigade 

For the 1st Marine Brigade, 
Kaneohe Bay, Hawaii, constant 
training for any possible contin- 
gency is a must. 

And for the 21st Dental Company 
— whose job is to keep the "bite" in 
the brigade — there's an equivalent 
training effort to ensure that com- 
pany personnel are always ready to 
move out with the marines. 

In each quarter of the year, the 
company's officers and technicians 
stage a week-long field-training 
exercise that has two objectives: 

• to keep personnel fully familiar 
with dental treatment techniques in 
the field, and 

• to test dental operating equip- 
ment under actual field conditions. 

Company personnel keep current on field treatment techniques. 

The company's field tents provide efficient working space for 4 dental officers and 5 technicians. 

U.S. Navy Medicine 

When the company arrives at its 
Field destination, four general- 
purpose tents are erected, each 
large enough to provide efficient 
working space for four dental offi- 
cers and five dental technicians. 

Two of the tents are used exclu- 
sively for providing routine dental 
treatments. The third tent contains 
two field operatories and a field 
X-ray unit, and can be used for 
screening examinations and emer- 
gency treatment. The fourth tent 
provides a waiting room and storage 

To erect a tent and set up all its 
equipment takes a mere 50 minutes, 
exclusive of electrical wiring. 

For its week in the field, the 
company routinely takes with it all 
the equipment and supplies needed 
for 10 dental officers to operate for 
30 days in the field. Field hospital 
sinks and autoclaves are set up in 
each operating tent, and two field 
X-ray units are on hand, as well as 
automatic film developers. 

During the company's most re- 
cent training exercise, its personnel 
were set up and ready to receive 
patients by the afternoon of the first 
day in the field. More than 200 pa- 
tients were seen in the first three 
days of the exercise, receiving the 
same level of care they would have 
been given in a permanent dental 

In the course of the exercise, all 
company personnel gained hands- 
on experience in setting up, working 
with, and breaking down each piece 
of equipment. At the exercise's 
completion, all equipment was field 
stripped, cleaned, and replaced in 
containers to await its next use. 

With this continual, vigorous 
training, the 21st Dental Company 
sees to it that its marines — whether 
in the field or in garrison — run no 
risk of losing their "bite." 

PA Named BUMED Consultant 

The Navy Medical Department's 
physician's assistants now have an 
active-duty representative serving 
as a consultant to the Medical Corps 
Division (Code 31) of BUMED. 

The PA consultant will act as an 
"ombudsman" and serve as liaison 
between BUMED and some 240 
physician's assistants in the field. 

The new consultant is CW02 
John E. Tissot, one of the original 
51 selectees for the Physician's As- 
sistant Program. He completed his 
didactic training in the program at 
Sheppard Air Force Base, Wichita 
Falls, Tex., in February 1974, and 
his clinical rotation at NRMC 
Charleston, S.C., the next year. 

Currently, CW02 Tissot is as- 
signed to the General Practice 
Clinic and the Internal Medicine 
Clinic at NRMC Charleston. He will 
be making periodic trips to BUMED 
as required in performance of his 
consultant duties, and one of his 
first efforts will be to make personal 
contact with all Navy PAs for their 

"My position as a consultant," 
he explains, "is a specific way to 
provide two-way communication: to 
bring needs and ideas from PAs in 
the field to the attention of the Sur- 
geon General, and to bring ideas 
from the Surgeon General to the 

CW02 Tissot entered the Navy in 
1966 and graduated from Hospital 
Corps "A" School at Great Lakes, 
111., in 1967. Subsequently he com- 
pleted Field Medicine Technician 
training in 1967 at Camp Lejeune, 
N.C., and Nuclear Submarine Medi- 
cine Technician training in 1970 at 
New London, Conn. 

From December 1967 to Novem- 
ber 1968, he served with the First 
Reconnaissance Battalion, First 
Marine Division, in Vietnam. 

Tissot was commissioned a war- 
rant officer in March 1975, upon 
completing training under the Phy- 

CW02 Tissol 

sician's Assistant Program. That 
same year he also completed re- 
quirements for a B.S. degree from 
the University of Nebraska. In 
March 1976, he was promoted to 

"The PAs have proven them- 
selves as professionals," he says. 
"As professionals, we are being ex- 
tended the privilege of having a 
voice in the control of our program. 

"I think PAs are a significant 
force. If we are allowed to function 
as we were trained, then I think we 
can help maintain the high stan- 
dards of Navy medicine." 

Volume 69, October 1978 

NOTAP Data Analysis Begins 

As reported earlier (see the April 
and June issues of U.S. Navy Medi- 
cine), the Navy Occupational Task 
Analysis Program (NOTAP) is work- 
ing with the Navy Medical Depart- 
ment on a thorough examination of 
various specialties of the hospital 
corpsman rating. 

Now the NOTAP study has moved 
into a new phase: data analysis. In 
May of this year, the first of 507 
completed task-inventory question- 
naires from corps men in the "Inde- 
pendent Duty/Afloat" specialty be- 
gan being fed into the hungry com- 
puters of the Navy Occupational 
Development and Analysis Center 

at the Washington Navy Yard. 

The "Afloat" analysis will be fol- 
lowed by analyses of questionnaires 
from corpsmen assigned to Fleet 
Marine Force units and from the 
"clinical specialists" — radiology 
technicians, pharmacy technicians, 
laboratory technicians, etc. 

NOTAP data will contribute to the 
updating of school curricula, occu- 
pational standards, and rate train- 
ing manuals, as well as to advance- 
ment in rate exams to meet the 
changing demands of the Navy 
Medical Department. 

Central office established. NO- 
TAP, the Bureau of Medicine and 

Surgery, and the Naval Health 
Sciences Education and Training 
Command have established a cen- 
tral office at the National Naval 
Medical Center, Bethesda, for con- 
duct of the Hospital Corps task 
analysis. This joint effort will thor- 
oughly review current management 
and training policies and practices 
and will solicit additional comment 
and opinion from other commands 
when appropriate. 

Questions or comments concern- 
ing NOTAP should be directed to 
HMCM Fred A. Burkhart, HM1 
David B. Crockett, or HM1 Louis C. 
Gerecz, Navy Occupational Task 
Analysis Program, Building 141, 
Room B-13, National Naval Medical 
Center, Bethesda, Md. 20014. Tele- 
phone: Commercial (202) 295-1486; 
Autovon 295-1486. 

At the Washington Navy Yard, CDR J.D. Holland, USN, who directs the Navy Occupational Development and Analysis Center, 
feeds the first of 507 "Afloat" questionnaires into an optical scanning device. CDR Walter A. Godfrey (MSC), former Hospital 
Corps Director (now Director of Administrative Services at NRMC Corpus Christi), looks on. 

U.S. Navy Medicine 


In the past, this column has been 
devoted to synopses of pertinent 
safety standards and the ways 
they relate to Navy medical facili- 
ties. This month, several items that 
have surfaced recently will be com- 
mented on. 

NFPA 76B, proposed Standard for 
the Safe Use of Electricity in Hos- 
pitals, was prepared and presented 
to the National Fire Protection As- 
sociation (NFPA) for adoption, but 
was not approved. 

The draft, presented at the asso- 
ciation's annual meeting, addressed 
the performance criteria for patient- 
care areas in new construction, and 
for new equipment to be used in 
patient-care areas. The American 
Hospital Association (AHA) ob- 
jected to the standard because in its 
view the effect of the document 
would be to add to the steady in- 
crease in health-care costs without 
adequate documentation of the 
existence of hazards to patients. 

Documentation of unsafe condi- 
tions or incidents is as difficult as 
projection of the cost of implemen- 
tation of any given standard. The 
data that can be gained by reporting 
unsafe or hazardous incidents will 
help to replace theory in these 
standards with reality. In the mean- 
time, the Navy is meeting with the 
Army and the Air Force to produce 
a standard on the safe use of elec- 
tricity in medical treatment facilities 
to fill the void left by this action of 
the NFPA. 

Should there be any reports of 
incidents or comments to be made 
on this new triservice standard, 
please send them to CAPT J. P. 
Swope, MC, USN, Department of 
the Navy, Bureau of Medicine and 
Surgery (Code 416), Washington, 
D.C. 20372. 

NFPA 56A, Standard for the Use of 

Inhalation Anesthetics, was revised 
and was also presented for adoption 
at NFPA's annual meeting. Amend- 
ments were offered from the floor 

• make isolation transformers 
optional in nonflammable anes- 
thetizing locations; 

• remove the requirement for the 
5-foot hazardous level in flammable 
anesthetizing locations and replace 
the hazardous location with a 25- 
centimeter distance from the source 
of flammable agents; 

• remove the requirement for 
electrical equipment in flammable 
anesthetizing locations to be ex- 

These amendments were disap- 
proved by the NFPA 56A Technical 
Committee. The document will be 
issued without the amendments 
unless the Standards Council or the 
Board of Directors reverses the 
Technical Committee's action. 

AHA is pursuing an appeal to the 
Standards Council of NFPA to re- 
verse the action of the Technical 
Committee and institute the amend- 
ments. Until the controversy over 
this document is resolved, the pre- 
vious standard applies. Operating 
room humidity will still have to 
be recorded daily, and hospitals 
throughout the entire country will 
have to continue to expend energy 
to humidify their OR suites. 

BUMED Code 416 is the Navy Med- 
ical Department's contact with the 
Joint Commission on Accreditation 
of Hospitals (JCAH) for safety, 
sanitation equipment and facilities. 
Items that have been resolved in- 
clude the need for checking the con- 
ductive floor when no flammable 
agents are used, and the need for 
openable windows in patients' 
rooms. In the First instance, con- 
ductive floors need only be tested 
once a year if they can be shown to 

have an average conductivity of 
greater than 25,000 ohms average 
resistance. The problem of open- 
able windows in patients' rooms has 
been alleviated by JCAH's inter- 
pretation that it is sufficient to have 
the key or tool required to open the 
window in a red box, similar to an 
elevator emergency key box, in the 
patient's room. 

BUMEDINST 10330.2 concerning 
medical gas pipeline systems was 
issued on 3 March 1978. Since then, 
many inquiries have been received 
at BUMED as to who is required to 
do the testing, how it is to be done, 
and where the equipment for it can 
be obtained. 

The instruction was issued be- 
cause of reports in the literature 
that had documented contaminated 
pipelines. The Naval Facilities En- 
gineering Command has issued a 
Guide Specification similar to the 
BUMEDINST. It is recommended 
that the testing be done on a con- 
tract basis. One available firm is 
Gollob Analytical Service, Inc., 
Berkeley Heights, N.J. 

With the advent of computers and 
digital signal processors and their 
incorporation into the various spe- 
cialties of the hospitals, concern for 
transient overvoltages in the utility 
power supply has emerged. 

One solution to many of the prob- 
lems in this area is presented by 
Bulletin No. 19 of July 1978— "Ap- 
plication/Installation Instruction for 
Power Line Transient Suppressors" 
— which can be procured from 
Chesapeake Division Naval Facili- 
ties Engineering Command, Build- 
ing 57, Washington Navy Yard, 
Washington, D.C. 20374. 

-CAPT John P. Swope, MC. USN, 
BUMED Code 416 

Volume 69, October 1978 

Notes 6 Announcements 

In memoriam . . . CAPT Howard H. Montgomery, MC, 

USN (Ret.), a former Navy physician who served 34 
years with the Navy Medical Corps, died 10 Sept 1978, 
at age 83. 

Born in Washington, D.C., CAPT Montgomery 
earned his M.D. degree from George Washington Uni- 
versity in 1917. Following graduation, he entered the 
U.S. Navy and subsequently served in many assign- 
ments including sea duty aboard the cruiser Pensacola 
and the battleship Texas. He also served at the sub- 
marine base in Panama; U.S. Naval Academy, Annapo- 
lis, Md.; Naval Hospital Philadelphia, Pa., where he 
was commanding officer; and at BUMED. CAPT Mont- 
gomery retired in 1951. 

CAPT Montgomery held the Legion of Honor from 
France and the Navy Commendation Medal. 

Dental continuing education courses . . . The following 
dental continuing education courses will be offered in 
January 1979: 

National Naval Dental Center, Bethesda, Md. 
Oral Pathology 8-12 Jan 1979 

Removable Partial Dentures 22-24 Jan 1979 

Eleventh Naval District, San Diego, Calif. 

Removable Partial Dentures 8-10 Jan 1979 

Oral Pathology 22-26 Jan 1979 

Maxillofacial Prosthetics 29-31 Jan 1979 

U. S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D. C. 

Oral Surgery 8-11 Jan 1979 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command {Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

Supercourse on lung diseases . . . The Fourth Annual 
New Orleans International Supercourse on lung dis- 
eases will be held 12-16 Dec 1978 at the Hyatt Regency 
Hotel, New Orleans, La. 
"Supercourse" is an intensive postgraduate program 

consisting of three separate courses running concur- 
rently for five days: 

(1) 15th Annual Pulmonary Function in Health and 
Disease Course is designed for the physician and will 
cover topics such as meaning and interpretation of lung 
function, lung response to injury, brain stem control of 
ventilation, shortness-of-breath syndromes, and moni- 
toring the critically ill patient. 

(2) 11th Annual Respiratory Care Course will include 
topics on nursing and respiratory priorities in the ICU, 
respiratory monitoring of the future, quality control in a 
respiratory care department, and the team approach to 
respiratory care. There will be an afternoon session on 
the rehabilitation and home care of the lung patient. 
This program is designed for the respiratory care team 
and is geared for physicians, nurses, and respiratory 
therapists who specialize in the treatment and manage- 
ment of lung patients. 

(3) 8th Annual Pediatric Pulmonary Course will be 
devoted to management of the infant in the intensive 
care unit. This course is primarily for physicians, but 
special seminars are included on the program for 
nurses and respiratory therapists who work in pediatric 
pulmonary departments. 

The annual program is sponsored by the American 
Lung Association of Louisiana and its medical section, 
the American Thoracic Society of Louisiana. Accredita- 
tions for the courses are from the American Medical 
Association in Category I, the American Academy of 
Family Physicians for prescribed hours, and the Ameri- 
can Association of Critical-Care Nurses. 

Tuition for the course will be $225. For additional in- 
formation and complete programs, write to ATS of 
Louisiana, 333 St. Charles Ave., Suite 500, New Or- 
leans, La. 70130. 

AFIP courses offered . . . The Armed Forces Institute of 
Pathology will offer the following courses: 

Head and Neck (Otolaryngic) Pathology Seminars 11-13 Dec 1978 

This clinically-oriented course will provide a review and update of 
pathology of the head and neck area related to salivary gland disease 
and neoplasia. Presentations will have a clinicopathology format 
designed for otolaryngologists, head and neck surgeons, oral sur- 
geons, and pathologists. 

Priority will be given applicants who are members of 
the Medical Corps of the Armed Forces or federal ser- 
vices in residency training in otolaryngology and pa- 

TJ. S. Navy Medicine 

thology specialties. Applicants who are military and 
federal medical service specialists in otolaryngology 
and pathology will be considered second. Applications 
from qualified civilians will be considered on a space - 
available basis. 

Seminars in Diagnostic Radiology 8-12 Jan 1979 

These seminars are designed to offer radiology practitioners a sum- 
mary of the most important morphological principles that underlie the 
evaluation of roentgenologic signs. Materials have been carefully 
chosen to achieve maximum radiologic-pathologic correlation in the 
elucidation of disturbed morphology as seen on roentgenograms. An 
added feature of the course will be an emphasis on radiologic study 
and evaluation in oncology, with particular stress on differential 
diagnosis and detection. 

Applicants should be members of the Medical Corps 
of the Armed Forces or federal services, or civilians 
with specialty training in radiology. 

Neuropathology 15-19 Jan 1979 

This course consists of a series of compact lectures in neuropathol- 
ogy. The lectures are designed as a general review of the funda- 
mentals of neuropathology, with emphasis on modern trends and 
interpretations. The lectures will be illustrated by gross and micro- 
photographs. A limited number of study sets of slides are available 
for loan, on a first-come-first- served basis, from the American Regis- 
try of Pathology, AFIP, and may be checked out during the course or 
by writing to the Registry at other times. 

Applicants must possess a doctoral degree and 
should be members of the Medical Corps, Dental 
Corps, or Veterinary Corps, with special interest in 
neuropathology. Applications from qualified civilians 
will be considered on a space-available basis. 

Further information may be obtained by writing to 
the Director, Armed Forces Institute of Pathology, 
ATTN: AFIP-EDZ, Washington, D.C. 20306. 

Occupational health workshop . . . The 21 sf Navy 

Occupational Health Workshop will be held 11-15 Dec 
1978 at the Cavalier Hotel, Virginia Beach, Va. In addi- 
tion to the workshop, Continuing Education Seminars 
will be given 9-10 Dec 1978. 

The workshop is directed to physicians, nurses, in- 
dustrial hygienists, medical safety officers and program 
managers, and should be of special interest to people in 
federal occupational health programs. Topics to be dis- 
cussed include radiation health, toxicology, asbestos, 
dental ventilation, ergonomics, welding hazards, waste 
anesthetic gases, optical hazards, hearing conserva- 

tion, environmental epidemiology, dermatitis, occupa- 
tional health nursing, and glaucoma screening. 

There is no registration fee. For further information 
write to LT G. E. Williams or Ms B. E. Halterman, 
Navy Environmental Health Center, 3333 Vine Street, 
Cincinnati, Ohio 45220. Telephone (Area code 513) 684- 
3863 or Autovon 989-3863. 

NAMI needs flight surgeon information . . , The Naval 
Aerospace Medical Institute (NAMI) in Pensacola 
would like to update its records concerning flight sur- 
geons who have died on active duty. The information 
will also be used to update NAMI's memorial plaque. 
Anyone who knows of a naval flight surgeon who died 
on active duty, particularly within the past 15 years, is 
requested to notify NAMI. Information should include 
name, rank, date and place of death and should be 
addressed to Commanding Officer (Code 013), Naval 
Aerospace Medical Institute, Naval Air Station, Pensa- 
cola, Fla. 32508. Telephone: Commercial (904) 452- 
2240; Autovon 922-2240 or FTS 948-2240. 

Tuition assistance for part-time outservice training . . . 

Medical Department personnel are encouraged to take 
advantage of part-time outservice training in accredited 
civilian institutions. However, in recent months several 
requests for tuition assistance have been disapproved 
because of late submissions and delays in mail delivery. 
BUMEDINST 1500.7D specifies that requests be sub- 
mitted prior to actual commencement of requested 
courses of instruction when practicable, but in all cases 
no later than 20 days after the course has commenced. 
Consideration will be given to late submissions, but 
legal restrictions on payment of after-the-fact obliga- 
tions must be applied when requests are received after 
the course is completed. In order to ensure favorable 
consideration of tuition assistance requests, applicants 
should inquire via their commands regarding the status 
of their requests, if they have not received notification 
of approval or disapproval within three to four weeks 
following submission. 

Inquiries should be addressed to: Commanding 
Officer, Naval Health Sciences Education and Training 
Command (Code 12), National Naval Medical Center, 
Bethesda, Md. 20014. Telephone: Autovon 295-1515. 
Commands are encouraged to forward photocopies of 
unanswered requests and endorsements via telecopier 
(295-1040) when necessary to ensure timely receipt. 

Volume 69, October 1978 

The Nurse Practitioner 

A look at how this new member of the health manpower 
team is doing, both with patients and with fellow 

professionals LCDRCharles H. Ingram, NC, USN 

The nurse practitioner has come into being in re- 
sponse to problems of inequitably distributed 
medical manpower, increasingly expensive health 
care, and the relatively small number of physicians 
interested in practicing primary medicine (/). 

Historically, the concept of health care in America 
has been synonymous with care by doctors (2). But 
more recently, increasing demands for health care and 
critical shortages of physicians have stimulated 
changes in the health-care-delivery system. Other pro- 
fessionals have claimed portions of health care as their 
domain (2). 

One result has been the development of various types 
of "nurse practitioner" roles, designed to relieve the 
physician of many routine tasks and provide the nurse 
with a non administrative avenue for upward mobility 
within nursing (3). 

The phrase often used to describe this development 
is "expanded role of the nurse." It refers to an ex- 
tended scope of nursing practice that includes such re- 
sponsibilities as obtaining the patient's health history, 
assessing health/illness status, and entering the pa- 
tient in the health-care system (2). 

Outside the military health-care community, clear 
definitions of nurse-practitioner roles, objectives, edu- 
cation and training, functions, and role relationships 
are at present hard to find (3). Perhaps this is due to the 
relative newness of the nurse in the expanded role of 
practitioner of health care. 

In the U.S. Navy, use of specialty-trained nurse prac- 
titioners was inaugurated to augment physician re- 
sources for delivery of primary health care in both out- 
patient and inpatient settings. The specific specialty 
areas designated for this expanded role are pediatrics, 

LCDE Ingram is clinical coordinator of the Internal Medicine 
Clinic, NRMC Corpus Christi, Tex. 78419. 

obstetrics and gynecology, and family practice (J). 

This is appropriate. Today's registered nurse is 
achieving higher levels of education than ever before. 
Licensing requirements are being updated throughout 
the United States. Nurses attaining high levels of 
achievement in certain specialty areas can now be certi- 
fied as well as licensed (4). The nurses provide direct 
services, usually in conjunction with a physician, to 
individuals, families, and other groups in a variety of 

Webster's dictionary defines "practitioner" as "one 
who practices a profession"; thus the term can be 
applied to any profession — medicine, law, dentistry, 
pharmacy, nursing, etc. 

Educators in baccalaureate and higher degree pro- 
grams in nursing have for many years perceived their 
mission to be the preparation of practitioners at the 
generalist and specialist levels (5). But perhaps the 
nurse has in the past been too often identified as one 
who is engaged in paperwork or in other non-nursing 
tasks. Too often, perhaps, he or she has been perceived 
as one who directs, teaches, or supervises others giving 
direct care (5). This may be the reason the title "nurse 
practitioner" often seems alien both to the nurse's co- 
professionals and to patients. 

Indeed, the idea of the nurse practitioner as a pro- 
vider of direct patient care can be difficult for some 
health-care consumers to understand. Frequently the 
patient will identify the nurse practitioner as a "doc- 
tor," even though the difference has been carefully ex- 

It is difficult to explain why it has been considered 
less prestigious for the nurse to give direct patient care 
than for others to do so. Yet, when one examines his- 
tory, that is precisely what happened, particularly 
during and following World War II. Direct nursing care 
was delegated to nurses' assistants, licensed practical 
nurses, and nurses' aides (5). Registered nurses are 

Volume 69, October 1978 

LTJG Virginia Stonebraker, pediatric nurse practitioner at NRMC Corpus Christ!, checks young patient. 

only now regaining some of their lost prestige and 
establishing territoriality on the health-care team as 
providers, rather than as directors, of care. 

BUMED Instruction 6550.4 defines the Navy family 
nurse practitioner as "a registered professional 
nurse who has acquired additional knowledge and 
skills as a result of an organized educational program 
recognized by the Bureau of Medicine and Surgery. 
This education prepares the nurse," the instruction 
continues, "to function in the expanded role in deliver- 
ing comprehensive health care and health maintenance 
to all age groups in ambulatory settings as a collabora- 
tive member of the health team." 

The instruction's definitions of the pediatric nurse 
practitioner and the obstetric/gynecological nurse prac- 
titioner are similar, but denote the subject areas of 
clinical practice. 

First and foremost, of course, the nurse practitioner 
is a nurse, whatever title he or she carries. But the 
practitioner is uniquely characterized by independence. 
And this independence may be perceived by coprofes- 
sionals as an invasion of their professional territory, 
especially where the nurse practitioner is new and un- 
known to coprofessionals (2). 

Despite their higher levels of education, nurses have 
encountered problems in taking on more responsible 
roles. Traditionally, the physician-nurse relationship 
has been one of extreme superordination-subordina- 
tion. Until recently, many physicians simply did not 
think of nurses as being capable of independent, or 
even cooperative, decision- making (6). Some continue 
to feel that way today, although in 1970 the American 
Academy of Pediatrics and the American Medical Asso- 
ciation both issued statements supporting expansion of 
the nurse's role. 


U.S. Navy Medicine 

Perhaps the largest hurdle for nurses to overcome 
has been their own psychological barrier: the feelings 
they have about themselves. Many cannot conceptual- 
ize themselves as being able to make diagnostic deci- 
sions. They have, of course, been making them for 
years but have protected themselves with elaborate 
games that cast the physician — the captain of the team 
— in the role of the only legitimate decision-maker (7). 

Many leading nursing educators argue, on a con- 
scious philosophical level, that the nursing role should 
focus primarily on the social and psychological prob- 
lems that accompany illness, rather than on patients' 
complaints (7). This is health care divided into "cure" 
and "care." 

The women's liberation movement has enlightened 
many and has helped to remove much of this kind of 
prejudice. As society gives more autonomy to all 
women, nurses are encouraged to take on more respon- 
sibility for decision-making in patient care. 

The entrance of more men into nursing is also help- 
ing the profession overcome some of the psychological 
barriers to role expansion, since most men feel foolish 
playing the "doctor-nurse game." 

As a result of these trends, some long-needed 
honesty seems now to be creeping into the interaction 
of nurses and physicians (7). 

How is the nurse practitioner gaining "professional 
territoriality" in order to give direct patient care? 
The avenues are three: professional organizations, 
legislation, and education (2). 

Professional organizations demarcate the line be- 
tween authorized and unauthorized practice. The pro- 
fessional organization must interpret practice, resolve 
disputes, and collaborate with other organizations in 
reaching settlements on territorial boundaries. Perhaps 
this is why we have seen increased rapport among the 
American Medical Association, the American Nurses 
Association, and other organizations these past few 

The second avenue, legislation, defines areas of 
expertise and areas of unauthorized practice (2). Recent 
changes in Nurse Practice Acts in many states are a 
welcome sign of response to the movement for expan- 
sion of the nurse's role (6"), but this does not mean that 
all problems on the legal front have been solved. 

The third avenue through which professional terri- 
toriality is being established is education. Once a func- 
tion is taught in a curriculum and is widely accepted by 
the profession, it becomes a part of the practice of that 
profession (2). (An example frequently used is that of 
the nurse's taking blood pressure — a function that at 
one time was considered to belong exclusively to the 

Since knowledge is expanding exponentially, the 
nursing profession is rapidly acquiring role extension 
(2). But this evolution adds further strain to territorial 


Questionnaire Respondents 

Seeing Physician 
(21 patients) 

Seeing Nurse 
(30 patients) 

Age 17-50 



Age 50 + 









Active duty 






(active duty) 






Nevertheless, though conflicts of professional terri- 
toriality exist, the nurse practitioner seems to have 
won a definitive place in the health-care commu- 
nity. But how does the patient-consumer view these 
new members of the health-care team? Is the patient 
satisfied with care delivered by someone other than a 
physician? Are the consumer's needs being met? 

These are questions we need to research and answer, 
so that the nurse practitioner can meet patients' needs 
more fully. 

As a start in this direction, the writer administered a 
questionnaire (Figure 1) to a mixed patient population 
in the Internal Medicine Clinic at NRMC Corpus 
Christi, where one nurse practitioner and two medical 
officers offer services. All three see male and female, 
active-duty and retired personnel. 

The patients were selected randomly and instructed 
to fill out the questionnaire after they had seen the 
health-care provider that day. A sample of 100 patients 
was attempted, but because the number of appoint- 
ments was limited as a result of leaves (the survey was 

TABLE 2. Patients' Identification of Practitioner 


of patients identifying physician as 



of patients identifying physician as nurse 



of patients identifying physician as other 



of patients identifying nurse practitioner 
as nurse practitioner 



of patients identifying nurse practitioner 
as physician 



of patients identifying nurse practitioner 
as other personnel 


Volume 69, October 1978 


FIGURE 1. Health Care Survey Questionnaire 

We in the Internal Medicine Clinic are interested in 
the care rendered to you. In order to help us find out 
how we can do a better job, we are asking you to answer 
this survey about the care you just received. Your an- 
swers will be kept private so you can feel free to answer 
the questions in a straightforward and honest way. 
Please check one answer for each question. 

Thank you very much for your help and if you have 
any problem with the questions, please ask for help. 

1. How would you rate the medical attention you re- 
ceived today? Was the medical attention given bet- 
ter than what most people get, about the same, or 
not so good? 

a. Better 

b. About the same 

c. Not so good 

(Scored 3-1) 

How would you regard your visit today as compared 
to a usual visit? 

a. Better than most visits 

b. About the same 

c. Not so good 

(Scored 3-1) 

How well do you feel you understand your present 

a. Very well 

b. I understand 

c. Not sure 

d. Don't understand it well 

(Scored 4-1) 

4. Which statement describes the person(s) who gave 
you medical attention today? 

(Scored 4-1) 

a. Extremely friendly 

b. Very friendly 

c. Friendly 

d. Not friendly 

5. How comfortable did the person giving you medical 
attention make you feel? 

a. Extremely comfortable (Scored 4-1) 

b. Very comfortable 

c. Comfortable 

d. Not very comfortable 

6. Would you say the person giving you medical atten- 
tion . . . 

a. Spent enought time with you (Scored 3-1) 

b. Spent too little time with you 

c. Spent more than enough time with you 

Did you feel that the person rendering care to you 
understood your problems? 

a. Understood very well 

b. Understood somewhat 

c. Didn't understand very well 

d. Didn't understand at all 

(Scored 4-1) 

8. How much interest and concern did the person giv- 
ing you medical attention show you? 

a. Extremely concerned (Scored 6-1) 

b. Very concerned 

c. Somewhat concerned 

d. Somewhat unconcerned 

e. Very unconcerned 

f. Extremely unconcerned 

9. How satisfactory was your contact with the person 
giving you care? 

(Scored 6-1) 

a. Extremely satisfactory 

b. Very satisfactory 

c. Somewhat satisfactory 

d. Somewhat unsatisfactory 

e. Very unsatisfactory 

f. Extremely unsatisfactory 

10. Who gave you medical attention today? 

a. Medical Doctor 

b. Nurse Practitioner 

c. Nurse 

d. Corpsperson 

e. Other 

11. Which statement best describes your feelings 
about the person who gave you medical attention 

a. I would prefer to see the same (Scored 3-1 ) 
person again 

b. It would make no difference whom I saw 

c. I would prefer to see someone else 

12. Please give the following information: 

a. Age 

b. Sex 

c. Status 

Active duty 


Active duty dependent 

Retired dependent 

13. Any additional comments you would like to make 
concerning the care you received today. 


U.S. Navy Medicine 

conducted in June of this year), only 51 responded. 

Some variables should be mentioned. One was my 
own time in the area. My work as Nurse Officer of the 
Day and my continuing education classes took me out of 
the clinic area on several occasions. Changes of person- 
nel in the clinic also affected the returns. Because of 
leaves and night duty of corps personnel, we frequently 
had new people working in the clinic. Although they 
were instructed on the importance of the survey, I 
found that personnel who were unaccustomed to the 
Internal Medicine Clinic were somewhat reluctant to 
ask patients to fill out the questionnaire. 

Another problem noted was that patients were 
frequently in a rush to leave the clinic once their visit 
was finished. Several took the questionnaire and 
agreed to complete it but left the clinic without doing 
so. Perhaps a mail-in form would have brought a better 

Since a determination of the level of consumer 
satisfaction was sought, I assigned a range of points for 
the possible responses to each question (Figure 1): the 
higher the level of satisfaction, the higher the number 
of points obtained. 

Each question was graded, averaged, and a percent- 
age level determined. Results of the survey are shown 
in Tables 1, 2, and 3. 

Overall satisfaction-level scores for the nurse practi- 
tioner and the physicians were close (Table 3). The 
nurse practitioner received a slightly higher rating from 
respondents on the medical attention received that day 
as compared with that received on previous visits 
(Question 2). The nurse also scored higher with respect 
to the patient's desire to return to the same provider of 
health care (Question 11). Additionally, the nurse prac- 
titioner scored higher when medical attention received 
that day was compared with "what most people get" 
(Question 1). 

The highest levels of satisfaction, with respect to both 
physicians and nurse, were in the area of their under- 
standing of the patient's problems (Question 7). The 
lowest level of satisfaction was scored by the 
physicians, and concerned the patient's perception of 
friendliness on the part of the person providing medical 
attention (Question 4), However, the nurse scored only 
slightly higher on the same item. 

One area that seemed to represent a problem was 
that of correct consumer identification of the nurse 
practitioner. As Table 2 indicates, the percentage of 
patients identifying the physicians correctly as medical 
doctors (86%) was much higher than that identifying 
the nurse practitioner correctly as a nurse (77%). 

I undertook this survey on the premise that when a 
health-care consumer seeks the services of a nurse 
practitioner, that consumer should receive satis- 
faction at least equal to that given by the traditional 
providers of health care. 

In this survey, the Navy nurse practitioner appeared 

TABLE 3. Satisfaction- Level Scores 








12 3 4 56789 11' 
•Question number 
X= nurse practitioner; • = physician 

to be meeting the needs of the patient-consumer popu- 
lation. In general, the scores for nurse practitioner and 
physicians ran closely parallel, indicating that from 
these consumers' perspectives the nurse in an ex- 
panded role is an acceptable addition to the health man- 
power team. 

At the bottom of the questionnaire was a space for 
comments. The nurse received only favorable com- 
ments, some examples of which are the following: "The 
nurse practitioner goes out of her way to be informa- 
tive" . . . "Her concern is most rewarding" , . . "Ex- 
tremely pleased with service" ... "I was somewhat 
apprehensive [about] being treated by a nurse, but 
changed my mind later because the nurse gave a thor- 
ough examination" . . . "Practitioner always appears to 
spend more time with patients." 

Many other areas touching nurse practitioners also 
need research — e.g., physician acceptance of nurse 
practitioners, economic factors, availability of nurses, 
availability of billets for nurse utilization, potential for 
further expansion of roles within the military setting, 

But with continued expansion and legalization of the 
"practitioner" role, it would seem that the nursing pro- 
fession can help alleviate the medical manpower short- 
age and offer a valuable service to consumers of health 


1. Lawrence R, et al: Physician receptivity to nurse practitioners: 
A study of the correlates of the delegation of clinical responsibility. 
Med Care 15:298-310, 1977. 

2. Monnig R: Professional territoriality: A study of the expanded 
role of the nurse. Aviat Space Environ Med 47:773-776, 1976. 

3. Fottler M, Pinchoff D. Acceptance of the nurse practitioner: 
Attitudes of health care administrators. Inquiry 13:262-273, 1976. 

4. Zimmerman A; Health care: Why bypass the nurses? Am 
Nurse 9:5, 1977. 

5. Macphail J: Nurse practitioner programs: Professional versus 
government pressures, influences, and goals. A nursing administra- 
tor's viewpoint. National League for Nursing Publication 15-1639, 
1976, pp 55-58. 

6. Bullough B: The law and the expanding nursing role. Am J 
Public Health 66:249-253, 1976. 

7. Bullough B: Influences of role expansion. Am J Nurs 76:1476- 
1481, 1976. 

Volume 69, October 1978 


Scholars' Scuttlebutt 

Naval Residencies: Dialogue Continued 

In June we reprinted in this column an exchange of 
letters between a young Reserve medical officer and 
the commanding officer of HSETC concerning Navy 
residency training. Those letters prompted the follow- 
ing correspondence, which concerns basic questions for 
Navy Health Professions Scholarship students about to 
embark on medical careers. 

RADM Stephen Barchet, MC, USN 

Commanding Officer 

Naval Health Sciences Education & Training Command 

National Naval Medical Center 

Bethesda, MD 20014 

Dear Sir: 

I read with extreme interest the recent exchange of 
letters between you and LT Herdener in the June issue 
of U.S. Navy Medicine. Since you seemed very open to 
hearing from naval scholars and anxious to discuss 
their career plans, I decided to write this letter. 

I am now entering my fourth year at Cornell Univer- 
sity Medical College and face the difficult decision of 
where to apply for my postgraduate training. For the 
naval scholarship student, this necessarily involves 
deciding whether or not to seek a naval residency. 

In my case, I think that both the best interests of the 
Navy Medical Corps and my own development as a 
physician will be best served if 1 take my pediatric 
training in a civilian institution. 

I quite agree with VADM Arentzen that "our training 
programs must be first rate," and with your observa- 
tion that, with respect to Ob-Gyn, "our programs will 
over the upcoming years remain fully competitive." I 
know you share LT Herdener's concern that, with the 
recent expiration of the Berry Plan, there is a real 
danger of the Navy Medical Corps losing the valuable 
input of physicians exposed to and trained in a great 
variety of programs. 

In order for us to remain "first rate," this cross- 
fertilization of diverse experience must be maintained. 
This is an absolute necessity if any intellectual commu- 

nity is to grow and flourish. This issue seems to me 
especially important now that the naval hospitals have 
assumed a primary teaching responsibility for students 
from the Uniformed Services University of the Health 

When I began to think about the kind of teaching 
situation which would be most advantageous, I came to 
the realization that the optimal environment for pediat- 
ric training would be that of the regional, university- 
affiliated children's hospital where the house officer is 
exposed to a large and diverse patient population, a full 
range of subspecialty services, and had the intellectual 
stimulation afforded by contact with an extensive pedi- 
atric attending and house staff. 

To my mind, none of the Navy programs fulfill these 
criteria. I have therefore decided to seek a three-year 

Upon completion of a civilian training program, I feel 
that I will bring a fresh and broadened perspective to 
the Navy Medical Corps. In addition, a three-year 
hiatus in a civilian hospital will give me a true front-line 
experience with health care delivery in the private 
sector, I would then be prepared to compare this with 
my four-year Navy experience and decide which of the 
two afforded me a more challenging and exciting envi- 
ronment. I am truly open-minded about my ultimate 
career goals; however, I would like to experience a hos- 
pital-based civilian environment before deciding wheth- 
er or not to remain in the Navy. 

I hope that I have expressed myself clearly. I have 
tried to be honest: we were told during ACDUTRA at 
Newport to clearly express our preferences to the Navy. 
I think that a three-year deferment, allowing me to train 
in a major children's hospital, will be beneficial to me 
and, ultimately, to the patients who rely on the Navy 
Medical Corps for their care. I appreciate your interest 
and look forward to any thoughts you might have. 

Thank you again for your time and consideration, 

ENS Kevin Shannon, MC, USNR 

425 E. 69th St. 

New York, N.Y. 10021 


U.S. Navy Medicine 

Dear Ensign Shannon: 

You have correctly surmised that I am deeply inter- 
ested in and committed to the mission, purposes and 
outcomes of Navy Medical Department education and 
training programs. Accordingly, as the Medical Depart- 
ment's "investment broker" for training to authorized 
Navy requirements, I am pleased to share in matters 
that deal with all 1,575 of our Health Professions 
Scholarship students. 

I would like to focus on that part of your letter in 
which you conclude Navy pediatric programs do not 
satisfy certain criteria — to wit: 

• a regional university-affiliated children's hospital 
where the house officer is exposed to a large and di- 
verse patient population, 

• a full range of subspecialty services, and 

• intellectual stimulation afforded by contact with an 
extensive pediatric attending and house staff. 

Additionally, you indicate some current indecision as 
to your Navy career intentions. In that vein you express 
a decided preference to seek a three-year deferment in 
order to complete a civilian training program in pediat- 

At the risk of overstating my bias in favor of the over- 
all worth, beneficial outcomes, and academic reputa- 
tion of Navy pediatric programs, I will not personally 
answer that part of your letter — because you know what 
that answer will be, and, quite possibly, you will not 
readily accept it. Instead, by copy of this and your 
letter, 1 am asking CAPT Bill McCurley to reply to you 
directly. CAPT McCurley is chairman of the Depart- 
ment of Pediatrics, National Naval Medical Center, and 
he holds the vice chairman's position at the Uniformed 
Services University. His clinical credentials, combined 
with a naval officer's dedication to Navy health care, 
are remarkable. I trust you will find his reply both inter- 
esting and persuasive. I, too, will look forward to read- 
ing his appraisal of Navy pediatric programs. 

As a naval officer nearing completion of enrollment 
in the Navy Health Professions Scholarship Program, 
you will no doubt shortly apply for first postdoctoral 
year training. In return for your scholarship, we expect 
that you will participate in the Navy Intern Program if 
selected for such participation, and that you will partici- 
pate in the Navy Residency Program — again, if you are 
competitive and selected to participate. 

Failing selection for participation in the Navy's 58- 
year-old intern program, and based upon the needs of 

the Medical Department, you are assured of a one-year 
deferment to complete a civilian internship or its equiv- 
alent. Those students following that pathway are well 
advised to seek out a well-rounded first postdoctoral 
year of broad medical, surgical, and preventive medical 

Uninterrupted continuation of civilian training made 
possible by selection for a full deferment in a basic 
specialty remains unlikely at the present. The Navy has 
an urgent and overriding need to assure adequate 
numbers of primary care medical officers are assigned 
to duty with the operating forces of our Navy and 
Marine Corps. This is a requirement for which there is 
no substitute, no alternative — and I must add that it is 
an opportunity which every Health Professions Scholar- 
ship Program student should seek to fulfill at the very 
earliest time in a professional role as a Medical Corps 

Unfortunately, it is not possible for every scholarship 
participant to be afforded this opportunity to work in an 
operational medicine assignment immediately upon 
completion of the intern year. For that reason opportu- 
nities exist for interns and others to apply for participa- 
tion in the Navy Residency Program, Selection is based 
upon a number of factors, including but not limited to 
noncognitive attributes, potential as a Medical Corps 
officer, demonstrated professional and military per- 
formance, past academic record, letters of reference, 
and availability of Navy residency positions. Applicants 
for the Navy Residency Program substantially enhance 
their chances for selection by first serving in a tour of 
duty with the operational forces, or as a flight surgeon, 
or as an undersea medical officer. 

Invariably, those medical officers adjudged as pro- 
fessionally qualified and eligible will be given first 
preference for the available Navy residency positions. 
To the extent that positions are vacant and the interns 
applying are not slated for an operational duty assign- 
ment, those interns who are competitive will be 
selected for participation in the Navy Residency Pro- 

Those Health Professions Scholarship Program par- 
ticipants who have been denied a position in the Navy 
Residency Program and who are otherwise profession- 
ally qualified may apply and compete for selection to be 
released from active duty for the period required to 
undergo civilian residency. Again, based upon the 
needs of the Medical Department, this is both a corn- 

Volume 69, October 1978 


petitive and a selective program which is administered 
in the Bureau of Medicine and Surgery (Code 3). The 
details, procedures, and policies governing this pro- 
gram are available by contacting CDR Clarence 
Mohler, MSC, USN (Retired), Code 314, in BUMED. 

Ensign Shannon, I hope you have gained from the 
tone and substance of my remarks a broader under- 
standing of the opportunities, procedures, and policies 
which bear upon Navy medicine, graduate medical 
education, and the Health Professions Scholarship Pro- 
gram. Also, I must presume that your perceptions stem 
from a personal worry that Navy pediatric programs are 
neither "first rate" nor "competitive." I remain opti- 
mistic as to the character and quality of the Navy's 
Graduate Medical Education Program, and I would 
hope that you share in that optimism. In support of my 
optimism is the Surgeon General's commitment to 
Medical Department education and training. In further 
support of that optimism is the unquestionable intent of 
the Congress, as set forth in PL 92-426, Chapter 105, 
Section 2121. This chapter, which deals with the Armed 
Forces Health Professions Scholarship Program, states 
in part: "In addition, members of the program shall, 
under regulations prescribed by the Secretary of De- 
fense, receive military and professional training and 

I believe profoundly in the military and societal worth 
of qualified physicians serving as Navy Medical Corps 
officers and their seeking participation in the Navy 
Graduate Medical Education Program. With the experi- 
ences gained [by the Navy Medical Department] from 
58 years of intern training and 33 years of residency and 
fellowship training, I further believe [it] will continue to 
train Medical Corps officers to become competitively 
proficient and competent specialists. I sincerely hope 
that we share similar objectives. 

RADM Stephen Barchet, MC, USN 

Commanding Officer 

Naval Health Sciences Education & 

Training Command 

National Naval Medical Center 

Bethesda, MD 20014 

Dear Ensign Shannon: 

Having reviewed your letter and RADM Barchet's 
response, I am happy to address your concerns from a 
pediatric vantage point. I do empathize with you. Your 
concerns are real and the decisions momentous. 

One might expect that my comments, too, may be 
somewhat biased, but I will attempt to present the facts 
objectively and then comment on them as they relate to 
Navy training programs. 

Of 234 university-affiliated graduate programs in 
pediatrics currently listed in the 1977-78 Directory of 
Accredited Residencies, 32 (or approximately 14%) 
are identified as associated with or located within 
"children's" and/or "infants'" hospitals. Notable ex- 

ceptions are Yale-New Haven, Johns Hopkins, Stan- 
ford, and Los Angeles County Medical Center, to name 
but a few. 

Children's hospitals indeed offer an exciting and 
unique environment for pediatric training. On the other 
hand, the overwhelming majority of pediatric care is 
rendered in general, multispecialty hospitals, and ap- 
parently many pediatricians, both clinical and aca- 
demic, have found such centers well able to meet their 
needs for specialty training. 

The Navy graduate programs are all located in large 
regional hospitals and are closely affiliated with local 
university medical centers. Most, if not all, of the pro- 
grams provide for elective experiences at these and 
other centers, depending upon the needs of the individ- 
ual resident. 

In-house subspecialty consultation services, of 
necessity, must be available at any hospital that has an 
accredited training program in pediatrics. To be sure, 
the extent and sophistication of these subspecialty 
services may vary considerably, but a medical center 
need not have subspecialty fellowship programs or 
grant-supported research programs to offer adequate 
consultative services. 

Navy programs generally provide a full range of con- 
sultative services, either in-house or, where necessary, 
from the locally affiliated medical centers, to satisfy 
both clinical and educational requirements. In addition, 
nationally prominent consultants are readily available, 
as they are at most civilian centers. 

I heartily agree that a good training program should 
provide an intellectually stimulating environment, and 
have always enjoyed that aspect of Navy Pediatrics 
wherever stationed. Furthermore, I will most certainly 
concur that diversity of background is a desirable qual- 
ity within a teaching faculty. Such diversity pervades 
the Navy programs. Clinical pediatric practice itself 
ensures that each pediatrician offers a slightly different 
viewpoint to the resident. Of interest, almost 80% of 
the Navy's 34 pediatric sub specialists received their 
subspecialty training in civilian institutions located 
throughout the United States. 

In summary, we each must determine our fate. We 
must closely examine the available options, decide 
wherein our interests and talents lie, and then set about 
to achieve our goals. 

Years ago, I decided that I wished to proffer a high 
caliber of pediatric care to my patients, continue in a 
professionally stimulating environment, teach at both 
the undergraduate and the graduate levels, and partici- 
pate in the more global aspects of pediatric health care. 
For me, the Navy Medical Corps satisfied these goals. I 
wish you the same degree of success as you embark 
upon your medical career. 

CAPT William S. McCurley, MC, USN 

Chairman, Department of Pediatrics 

National Naval Medical Center 

Bethesda, MD 20014 


U.S. Navy Medicine 

IMAVMED Newsmakers 

No excitement in the life of a physi- 
cal therapy technician? 

Not so, especially if you happen 
to be HM2 Roy J. Trissel, a six-year 
veteran of naval service assigned to 
NRMC Okinawa. 

On 3 March 1978, Petty Officer 
Trissel saw a CH-46 helicopter go 
down in the China Sea near the 
Okinawa coastline. Though he was 
fully aware of potential personal 
danger, he entered the water with- 
out hesitation, waded out to the 
downed aircraft, and began work to 
rescue its occupants. 

During his rescue attempts, he 
was constantly exposed to dangers 
from explosion, shifting wreckage, 
and fuel burns — and he did in fact 
incur fuel burns about the eyes. 
Nothing daunted, with the aid of 
one other hospital corpsman and a 
marine, he had managed to free 
the chopper pilot and a crewmem- 
ber by the time trained rescue per- 
sonnel arrived on the scene. 

On 10 August, HM2 Trissel was 
awarded the Navy and Marine 
Corps Medal for heroism, presented 
by CAPT C.S, Lambdin (MC), com- 
manding officer at NRMC Okinawa. 

The citation's conclusion summed 
it all up well: "Petty Officer Tris- 
sel' s courageous and prompt actions 
in the face of great personal risk re- 
flected great credit upon himself 
and were in keeping with the 
highest traditions of the United 
States Naval Service." 

RADM David B. Carmichael, MC, 

USNR-R — the senior medical officer 
of the Naval Reserve — recently 
closed out the Navy half of his dis- 
tinguished military and medical 
career with appropriate awards and 
a flourish. 

During a formal retirement cere- 
mony at the San Diego Naval Re- 
serve Center, RADM Carmichael 
was awarded the Legion of Merit for 
"exceptionally meritorious conduct 

in the performance of outstanding 
service ..." That award and a Cer- 
tificate of Merit were presented to 
RADM Carmichael by VADM Wil- 
lard P. Arentzen, MC, USN, Navy 
Surgeon General. 

Other speakers at the ceremony 
were RADM Richard Lyon, USNR, 
Deputy Chief of Naval Reserve, who 
brought a Letter of Appreciation 
from the Chief of Naval Reserve, 
and RADM John W. Cox, MC, 

HM2 Trissel: Heroism rewarded 

USN, Commanding Officer of 
NRMC San Diego, who added his 
personal tribute. 

In his own speech, RADM Car- 
michael recalled that in a one-week 
period in December 1950, he and 
his staff had expanded the capacity 
of the Yokosuka Naval Hospital 
nearly eightfold, from 700 to 5,500 
— an achievement for which they 
were awarded the Presidential Unit 

RADM Carmichael entered the 
Naval Reserve in 1955, with duties 
that included service as Inspector 
General, Medical, U.S. Naval Re- 
serve, and Deputy Special Assistant 
to the Surgeon General for Medical 
Department Education and Train- 

Though RADM Carmichael has 
now transferred to the Retired 
Reserve, he will still be keeping 
busy as clinical professor of medi- 
cine at the University of California - 
San Diego School of Medicine and 
vice chairman of the AMA's Resi- 
dency Review Committee in Inter- 
nal Medicine. 

VADM Arentzen; RADM and Mrs. Carmichael; RADM Cox 

Volume 69, October 1978 


Instructions & Directives 

Sampson P-3 frame for use with submarine EAB mask 

Submariners who are supplied with spectacles under the provisions of BUMED Instruction 
6810. 4E have complained that they are unable to wear the standard issue S-10 black acetate 
military eyewear under the EAB mask without compromising the critical seal and/or contend- 
ing with very uncomfortable facial pressure. 

An informal evaluation of several commercially available frames resulted in selection of the 
American Optical Corporation's Sampson P-3 frame as one that would meet the criteria of not 
interfering with the seal of the mask or the comfort of the wearer. However , the demand for 
these relatively expensive frames has significantly exceeded estimates and caused severe 
budgetary strain. 

The Naval Submarine Medical Research Laboratory is informally evaluating cheaper alter- 
natives to the Sampson frames and planning to study a new EAB mask. Further evaluation of 
this problem will be included in an upcoming formal review and study of visual standards for 

Action. Submariners who require prescription spectacles to perform their duties while 
wearing the EAB mask shall be provided with a spectacle frame suitable for use with the 
mask. This frame will be the Sampson P-3 frame until a less expensive one can be located and 
tested. Requisition shall be in accordance with BUMEDINST 6810. 4E. Issue shall be limited to 
those personnel whose watch stations or emergency bill duties absolutely require, as deter- 
mined by the commanding officer, 20/20 vision and are essential to the safe and efficient 
operation of the ship. Issue shall also be limited to those personnel with refractive errors that 
exceed the following limits: 

• Myopia. Refractive error exceeds -0.75 sphere or spherical equivalent (the algebraic sum 
of the spherical correction plus one half the cylindrical correction) or has a cylindrical correc- 
tion that exceeds 1.00 diopter. 

• Hyperopia. Refractive error that exceeds +1.00 sphere or spherical equivalent or has a 
cylindrical correction that exceeds 1.00 diopter. These lens power restrictions do not apply to 
presbyopic personnel who are over 35 years of age. — BUMED Notice 6810 of 20 June 1978. 

Two required publications — and how to get them 

BUMED Instruction 6820. 4K requires all Medical Department activities to procure and main- 
tain current editions of the Manual of Naval Preventive Medicine (NAVMED P-5010) and 
Control of Communicable Diseases in Man (published by the American Public Health Asso- 

• Recently, several chapters of NAVMED P-5010 have been out of stock at the Naval Publi- 
cations and Forms Center, Philadelphia. The stocks were allowed to become depleted because 
it was anticipated that the chapters would be revised. Unfortunately, the revisions have not 
been forthcoming. 

To meet the needs of Navy medical activities until the revised chapters become available, a 
limited supply of current chapters has been printed. These chapters may be ordered from the 
Commanding Officer, Naval Publications and Forms Center, 5801 Tabor Ave., Philadelphia, 
Pa. 19120, using the following stock numbers: 

Stock No. 0510-LP-027-0010: Chap 1, Food Sanitation. 

Stock No. 0510-LP-027-0002: Sup 1, The Vending of Food and Beverages. 

Stock No. 0510-LP-028-0000: Chap 2, Sanitation of Living Spaces and Related Service Facil- 

Stock No. 0510-LP-029-0005: Chap 3, Ventilation and Thermal Stress Ashore and Afloat. 

Stock No. 0510-LP-030-0000: Chap 4, Swimming Pools and Bathing Places. 

Stock No. 0510-LP-031-0005: Chap 5, Water Supply Ashore. 

Stock No. 0510-LP-031-1002: Chap 6, Water Supply Afloat. 

Stock No. 0510-LP-032-0000: Chap 7, Sewage Disposal Ashore and Afloat. 

18 U.S. Navy Medicine 

Stock No. 0510-LP-033-0000: Chap 8, Medical Entomology and Pest Control Technology. 

• Control of Communicable Diseases in Man may be ordered in accordance with procedures 
outlined in BUMED Instruction 6820. 4K, from the American Public Health Association, 1015 
18th St., N. W., Washington, D.C. 20036; price, $4 per copy.— BUMED Notice 5600 of 30 June 

' Integral parts of training': guidelines 

An "integral part of training" is an approved course or affiliated period of training necessary 
to supplement experiences in approved Medical Department training programs and meet the 
requirements for accreditation set by recognized accrediting bodies. 
HSETC will: 

• Authorize sponsorship for attendance at programs that have been approved by BUMED 
as an integral part of an approved training program. 

• Monitor accreditation requirements of Navy Medical Department training, and review all 
requests for integral parts submitted to BUMED for approval. All approved integral parts will 
be reviewed by HSETC at least annually for currency, appropriateness, and cost. 

• Fund appropriate costs incident to participation of qualified Navy Medical Department 
personnel in approved integral parts of approved training programs. 

Courses that are considered essential and are pending approval as an integral part may be 
sponsored by local commands to the extent that funding permits. 

Requests to establish new integral parts should be submitted to the Chief, BUMED (Code 
0011), via Commanding Officer, HSETC. Requests must include the course or program title, 
location, sponsorship, number of participating trainees, projected travel costs, fees, and any 
other related costs. Each request must justify the proposed integral part and outline the train- 
ing deficiencies that require its approval. 

Attendance at periodic or annual meetings of scientific, technical, or professional confer- 
ences are within the purview of BUMEDINST 4651. IB. 

Procedure. Letter requests for attendance in an approved integral part of an approved 
training program shall be prepared in the format of the sample letter of application provided 
as enclosure (1) of this instruction. The payment of fees or related expenses from personal 
funds, subject to reimbursement by the government, may be made prior to receipt of Com- 
manding Officer, HSETC, authorization if the integral part has been approved by BUMED. 
Requests should be received in HSETC six weeks prior to the period of training to ensure 
timely processing and response. 

MOU for Navy trainees. Occasionally, circumstances may indicate the need for a Memoran- 
dum of Understanding (MOU) to cover Navy trainees while they get training or clinical experi- 
ence at a nonfederal institution. In such cases, the commanding officer is authorized to nego- 
tiate and forward to BUMED (Code 0011), via the Commanding Officer, HSETC, an MOU 
prepared in accordance with the format and language of the sample provided as enclosure (2) 
of this instruction. Note that this MOU and procedures are distinctly different from the MOU 
for nonfederal trainees in naval activities authorized by BUMEDINST 12000. 5E. 

Travel and liability. BUPERSINST 1321. 2H discusses TEMADD and authorization orders, 
while Public Law 94-464 is the federal malpractice statute that protects Navy Medical Depart- 
ment personnel. Each must be carefully reviewed. 

BUPERSINST 1321. 2H clearly prohibits use of authorization orders in connection with offi- 
cial Navy business. Public Law 94-464 requires a member to be acting within the scope of his 
official duties to be entitled to the immunity provisions of the law. Thus, since the nature of 
approved integral parts training is official business, Navy Medical Department trainees shall 
not be required or permitted to participate in approved integral part training of approved 
training programs at no cost to the government. — BUMED Instruction 1500. 13A of 2 May 

Volume 69, October 1978 19 

Education & Trainin 


San Diego Courses for DTs Outlined 

This is the second in a series of 
articles outlining the educational 
opportunities available to dental 
technicians at the Naval School of 
Dental Assisting and Technology, 
San Diego, Calif, 

Course B-331-0016: The Dental 
Laboratory Technology, Basic, 
Class C School, a six-month course 
of instruction, convenes classes 
quarterly. As with all other courses 
offered at the Naval School of Den- 
tal Assisting and Technology, major 
curriculum revisions have been 
completed, assuring that the train- 
ing more closely parallels the post- 
graduate training received by dental 

officers at the National Naval Dental 
Center, Bethesda, Md. 

In response to BUMED direction, 
this course has been converted to a 
modularized, task-based method of 
instruction, with primary emphasis 
placed on the BUMED-approved 84- 
item task inventory for the NEC 

The course is designed to teach 
the trainee the basic skills neces- 
sary to function effectively in a 
prosthodontic laboratory in the 
areas of complete-denture and re- 
movable-partial-denture construc- 
tion and all associated tasks. 

Instruction includes: 

DTC G. Harbert gives advanced students a porcelain color staining demonstration. 


• Module 1, Prosthodontic Labo- 
ratory Fundamentals. An introduc- 
tion to the modular system, vocabu- 
lary, oral anatomy, and prostho- 
dontic laboratory clerical proce- 

• Module 2, Basic Laboratory 
Procedures. Includes supplemen- 
tary tasks, such as construction of 
diagnostic casts, individualized 
trays, master casts, record bases, 
and occlusion rims. 

• Module 3, Complete Denture 
Construction. Anatomical and mon- 
oplane tooth arrangements, im- 
mediate denture arrangements, 
processing with heat-curing acrylic 
resin, and acrylic and tooth repairs. 

• Module 4, Removable Partial 
Denture Construction. Includes 
chrome -cobalt framework construc- 
tion, altered cast techniques, ar- 
rangement of teeth, and processing 
with heat-curing acrylic resin, 

• Module 5, Fixed Partial Den- 
ture Construction. An introduction 
to complete crown and fixed partial 
denture framework construction. 
Includes cast construction, waxing 
of patterns, and casting and finish- 
ing frameworks. 

Students progress through these 
modules at their own pace, within 
specified time limits. The facilita- 
tor/student ratio is maintained at 
1:10, affording maximum opportu- 
nity for individualized instruction. 

Course B-331-0017: The Dental 
Laboratory Technology, Advanced, 
Class C School, also a six-month 
course of instruction, convenes 
classes semiannually. 

This course was also recently con- 
verted to the modularized, task- 

U.S. Navy Medicine 

In the Advanced, Class C School, demonstrations and practi- 
cal experience go hand in hand. 

based method of instruction. Em- 
phasis is placed on advanced tech- 
niques in the construction of re- 
movable and fixed prosthodontic 
appliances associated with the NEC 
8753. Also taught are administra- 
tive and supervisory skills that will 
enable the trainee to function effec- 
tively in the capacity of prosthodon- 
tic laboratory supervisor. 
Instruction includes: 

• Module 1, Complete Denture 
Construction. Advanced techniques 
in tooth arrangement, acrylic char- 
acterization and processing, using 
pour-acrylic techniques. 

• Module 2, Removable Partial 
Denture Construction. Construction 

of appliances adjunct to other dental 
specialty treatment, and construc- 
tion of removable appliances pre- 
scribed in conjunction with fixed 
prosthodontic treatment. 

• Module 3, Fixed Partial Den- 
ture Construction, Fixed partial 
denture framework construction, 
ceramics, staining, characteriza- 
tion, and acrylic veneering. 

A review of basic techniques is 
included in each of the above mod- 
ules. As with all other courses at the 
dental assisting school, students 
progress through the modules at 
their own pace. The facilitator/ stu- 
dent ratio, maintained at 1:6, as- 
sures maximum opportunity for in- 

dividualized instruction. 

How to apply. Dental technicians 
interested in applying for either of 
these courses should refer to the 
Catalog of Navy Training Courses, 
NAVEDTRA 10500, to determine 
eligibility requirements. 

Applications should be submitted 
to the Chief of Naval Personnel 
(Pers 5), via the Chief, Bureau of 
Medicine and Surgery (Code 611), 
in accordance with article 2.02 of 
the Enlisted Transfer Manual. 

The recommendation for person- 
nel requesting training in dental 
laboratory technology must be from 
a dental officer practicing in the 
area of prosthodontics. 

Volume 69, October 1978 


Dental Information Retrieval System: 

Planning for Tomorrow's Needs Today 

The need to use scarce resources 
in an efficient and effective 
manner is a major concern of 
both government and industry. It's 
a concern shared by the Navy Den- 
tal Corps, which has taken steps to- 
ward allocating its assets so that 
resources expended obtain the 
greatest possible return. 

In April 1975, the Dental Corps 
completed an analysis of its system 
for collecting dental treatment in- 
formation. The study showed that 
even though the system adequately 
recorded clinical evaluation data 
and treatment procedures provided, 
it had a number of deficiencies. For 
one thing, it required multiple 
manual steps to collect and compile 
data. Moreover, it provided no data- 
collection capability for determining 
the treatment needs of the Navy and 
Marine Corps population. 

In this era of austere budgets, the 
Dental Corps will be required to 
present detailed justifications for 
budget requests and future pro- 
grams. Commanders will need more 
precise data on current and future 
workload requirements if they are to 
substantiate requests for manpower 
and facilities that will provide an ef- 
fective dental care delivery system. 

At present, management must 
rely solely on the historical data col- 
lected via DD-477/NAVMED 6600/ 
7 to develop and substantiate dental 
budgets and programs. This process 
measures only a portion of the de- 
mand for dental care, rather than 
measuring all the needs for dental 
care in the eligible population. 

For truly effective management, 

the Dental Corps must be capable of 
presenting budgets and programs 
in terms of treatment requirements 
(needs). As a result of the analysis 
performed in 1975, the Dental Divi- 
sion began to develop and test a 
computer-based data- collection sys- 
tem — the Dental Information Re- 
trieval System (DIRS) — designed to 
provide this information. The es- 
sential element of this system is a 
simple, inexpensive, optical-mark, 
machine-readable input form. 

A number of forms have been 
tested and evaluated at the National 
Naval Dental Center, Bethesda, 
Md., and the Naval Regional Dental 
Center, Norfolk, Va. DIRS has now 
evolved into a two-part system, 
using one form to collect data on 
treatment requirements and a 
second form to collect data on treat- 
ments provided. 

Use of the treatment-requirement 
form began at all regional dental 
centers in July of this year. 

The second form — which will use 
a modification of the American 
Dental Association's coding system 
for treatment provided — is still 
being tested. Since the second 
form's purpose is to measure the 
quantity of treatment provided, it is 
expected to replace DD-477 in the 

The treatment-requirement form 
is to be completed for one out of 
every five (20%) of the active- duty 
Navy and Marine Corps personnel 
who report to regional dental facili- 
ties for annual dental examinations. 
Completed report forms are for- 
warded to BUMED (Code 6141) 

once each week, or more often if 

As the data base thus provided 
grows, it will be possible to deter- 
mine the specific resources required 
to treat these needs. This will be 
done by converting the treatment- 
requirement categories statistically 
to specific DD-477 treatments. 
These will then be converted by 
time-weight factors to treatment 
time required (in minutes). Finally, 
the dental treatment minutes re- 
quired will be converted to dental 
officer requirements. 

When DIRS has been completely 
implemented, it will provide a 
number of benefits over the current 
system. These include: 

• Ability to obtain and document 
all the dental information required 
by existing directives. 

• Provision of more timely and 
sensitive data measurements to 
heaquarters — and better feedback 
to field activities. 

• Significant reduction in the 
probability of reporting errors. 

• Reduction of the administrative 
burden in collecting, reporting, and 
analyzing data. 

• Provision of a more compre- 
hensive data base, allowing more 
accurate responses to internal and 
external inquiries. 

• Provision, to all levels of 
management, of the information 
necessary for accurate and realistic 
planning for a more efficient and 
effective allocation of resources. 

-LTGary J. Spinks, MSC, USN 
BUMED Code 6141 


U.S. Navy Medicine 


Reducing the Crossmatch Time 

LCDR W. Patrick Monaghan, MSC, USN 

Recent work performed at the National Naval Medi- 
cal Center in Bethesda, Md., has resulted in a rapid 
compatibility test used to define recipient blood for pa- 
tient transfusion purposes. 

The saline low ionic crossmatch (SLIC) is a method of 
performing compatibility testing between patient and 
donor red cells with only a 10- minute incubation phase. 
The full crossmatch can usually be completed within 20 
to 30 minutes. 

The SLIC procedure, which incorporates low ionic 
strength solution (LISS), has also proved to be more 
sensitive than the traditional crossmatch, which gener- 
ally uses a 45- to 90-minute test procedure, and it has 
detected the presence of alloantibodies previously 
missed by the conventional crossmatching methods. 

Overall, the SLIC procedure has proven to be 
efficient and sensitive in performing red cell compati- 
bility testing and is readily adaptable for both routine 
and emergency crossmatching techniques. 

LISS in the hemagglutination reaction 

The increased rate of reaction between immunoglob- 
ulins and red cell antigenic sites has been observed 
when the hemagglutination reaction occurs in a low 
ionic environment (1-12). 

Hughes- Jones (J) in 1964 reported a 1,000-fold in- 
crease in the uptake of the radio-labeled anti-Rh (D) 
onto homozygous Rh-positive red cells when they were 

LCDR Monaghan (Ph.D.), an immunohematologist, heads the 
Blood Bank of the National Naval Medical Center, Bethesda, Md. 

This work was supported by the Naval Medical Research and 
Development Command, Department of the Navy, under Research 
Work Unit M0096-PN. 01-0049. 

reacted in a low ionic strength solution of approxi- 
mately 0.3M. 

Other immunohematologists have found this low 
ionic environment both to enhance the specificity of the 
hemagglutination reaction and to increase the rate of 
reactivity (6-10). 

One mechanism responsible for this effect is the re- 
duction of the natural electrostatic barriers between red 
cells that are in opposition to each other. There is 
further evidence that the low ionic chemicals may also 
cause the immunoglobulins to aggregate partially, prior 
to attachment to the red cell membrane antigens. This 
effect may be responsible for the increased sensitivity 
observed when LISS is used as a red cell suspending 
medium in the indirect anti-human globulin testing 
phase. This enhancement of sensitivity is probably due 
to the clustering of specific immunoglobulins onto the 
reciprocal red cell antigenic sites in localized areas of 
the red cell membrane. The clustering would increase 
the likelihood that the second phase of agglutination 
would occur: formation of a lattice network between 
previously sensitized red cells coated with antibody. 
This lattice formation is what actually accounts for the 
avidity observed in the hemagglutination reaction. 

The chemical solutions used in the SLIC procedure 


LISS Dry Pack 




18.0 grams 


14.0 milligrams 


1.79 grams 

NaH 2 P0 4 

180 milligrams 

NaHP0 4 

213 milligrams 

Volume 69, October 1978 


TABLE 2. Saline Low Ionic Crossmatch 
(SLIC) Procedure 

1. Wash red blood cells (patient or donor) once with 
normal saline. 

2. Wash red blood cells once with LISS. 

3. Decant and resuspend cells to a 5% cell suspension 
in LISS. 

4. Mix 2 drops of serum with 1 drop of 5% cell suspen- 

5. Incubate duplicate sets of tubes at room tempera- 
ture and at 37°C for 10 minutes. Centrifuge and 

6. Wash 37°C tubes three times with normal saline. 

7. Add 2 drops of anti-human globulin serum. 

8. Centrifuge and read. 

have proven to be comparatively inexpensive, and ob- 
viate the need for using the 22% bovine albumin com- 
monly employed in the conventional crossmatch pro- 

The low ionic strength solution (LISS) used in the 
SLIC procedure is a modification of the Low and Messe- 
ter (7) formula. Table 1 lists the ingredients, which can 
be preweighed and packaged in a plastic envelope. 
These packets are later reconstituted with one liter of 
distilled water and the pH adjusted, if necessary, to a 
range of 6.5-7.2. This solution can then be used to wash 
and suspend the red cells according to the SLIC pro- 





30 MIN. 






10 MIN. 



cedure listed in Table 2. The red cell solution prepared 
with LISS can be used for 24 to 48 hours without any 
loss of hemagglutination enhancement. 

LISS solutions should be stored at standard blood 
bank refrigeration, 4°C, and are readily used within a 
few days. 

Two commercial companies have recently marketed 
the Low and Messeter formula of LISS. One company is 
selling the LISS in a liquid 200-ml wash bottle. The 
other sells the LISS formula in a lypholized bottle that 
can later be reconstituted to a 200-ml volume. 

More recent work indicates that a low ionic solution 
in an additive droplet form may be even more advanta- 
geous for routine use in immunohematological testing. 
Many other proprietary firms are currently working on 
solutions that affect the low ionic milieu of the hemag- 
glutination reaction, thereby providing a more sensitive 
and specific reaction between red cell membrane anti- 
gens and their reciprocal alloantibodies. 

Comparative crossmatch study 

A one -year blind study comparing the SLIC pro- 
cedure with the routine conventional procedure was 
conducted at the National Naval Medical Center Blood 
Bank (Figure 1). The results of this initial study were 
presented in November 1977, at the thirtieth annual 
meeting of the American Association of Blood Banks in 
Atlanta, Ga. (13). The report is presently pending pub- 
lication in the journal Transfusion. 

The findings in this study on three patients who had 
clinically significant alloantibodies of three different 
specificities, undetectable by the conventional cross- 
match technique, elaborated the superior sensitivity of 
the SLIC procedure. 

Additional immunohematological tests that used the 
patients' sera, LISS, and red cells of known antigenic 
composition defined the specificity of the alloantibodies 
found in the three patients' sera. 

Thirty alloantibodies were detected throughout the 
study. All of these antibodies showed enhancement 
when the SLIC procedure was used. 

Other pertinent findings in the study corroborated 
the increased sensitivity and enhancement of the 
hemagglutination reaction that had been previously re- 

No false-negative results were elaborated in the 
study when the SLIC protocol was used. However, 
some weak false-positive crossmatches were noted, 
which were attributed to the activation of the comple- 
ment components and the use of polyspecific (broad 
spectrum) anti-human globulin sera (Coombs) that 
contained anti-complement. 

Because of the obvious attributes of the SLIC pro- 
cedure — notably increased sensitivity, terminated use 
of bovine albumin, and the considerable amount of time 
saved in determining compatibility — the procedure was 
implemented at the National Naval Medical Center as 


U.S. Navy Medicine 

the standard compatibility test. Since that time, more 
than 25,000 units of both refrigerated bank blood and 
frozen-thawed-deglycerolized red cells have been 
crossmatched without any difficulty. Although many 
clinicians were not aware of the actual change to the 
SLIC procedure, numerous anesthesiologists and sur- 
geons have complimented members of the blood bank 
staff on their responsiveness in providing fully cross- 
matched blood in such a comparatively timely fashion. 

Other aspects of low ionic solutions that are presently 
being studied are their stability upon prolonged storage 
for use aboard ships and in field hospitals, a platelet/ 
granulocyte crossmatch in support of hematology- 
oncology patients, and an automated crossmatch pro- 
cedure using a 10-channel autoanalyzer. 

The benefits have been obvious to all who have used 
the low ionic procedure, and the savings in medical 
laboratory technicians' time and fiscal resources have, 
furthermore, proven to be significant. The ability to 
respond quicker, using a more sensitive index for com- 
patibility support of patients who are receiving hemo- 
therapy, is perhaps the greatest attribute of the saline 
low ionic crossmatch. 


1. Elliott M, Bossom E, Duput MD, Masouredis SP: Effect of 
ionic strength on the serologic behavior of red cell antibodies. Vox 
Sang 9:396, 1964. 

2. Moliison PL, Polley MJ: Uptake of globulin and complement 

by red cells exposed to serum at low ionic strength. Nature 203:535, 

3. Hughes- Jones NC, Gardner B, Telford R: The effect of pH and 
ionic strength on the reaction between anti-D and erythrocytes. Im- 
munology 7:72, 1964. 

4. Hughes- Jones NC, Polley MJ, Telford R, Gardner B, Klein- 
schmidt G: Optimal conditions for detecting blood group antibodies 
by the antiglobulin test. Vox Sang 9:385, 1964. 

5. Atchley WA, Bhagavan NV, Masouredis SP: Influence of ionic 
strength on the reaction between anti-D and D positive red cells. J 
Immunol 93:701, 1964. 

6. Barnes AE: The specificity of pH and ionic strength effects on 
the kinetics of the Rh(D) and anti-Rh(D) system. J Immunol 96:854, 

7. Low B, Messeter L: Antiglobulin test in low ionic strength salt 
solution for rapid antibody screening and crossmatching. Vox Sang 
26:53, 1974. 

8. Moore HC, Moliison PL: Use of alow ionic strength medium in 
manual tests for antibody detection. Transfusion 16:291, 1976. 

9. Moore HC, Sipes BR: The effects of ionic strength on antibody 
uptake with special reference to the antiglobulin test, in Pollack W, 
Moliison PL, Reiss AM (eds): An International Symposium on the 
Nature and Significance of Complement Activation. Ortho Research 
Institute, 1976, pp 119-127. 

10. Wicker B, Wallace CH: A comparison of low ionic strength 
saline medium and routine methods for antibody detection. Trans- 
fusion 16:469, 1976. 

11. Sipes BR: The effect of the low ionic strength solutions on the 
detection of blood group antibodies. MS thesis, University of Tennes- 
see, 1975. 

12. Monaghan WP, Dickson LG, Moore HC, Sipes BR, Oleynick 
NJ: The saline low ionic crossmatch (SLIC). Am J Med Technol 43:5, 

13. Monaghan WP, Dickson LG, Moore HC, Sipes BR, Oleynick 
NJ: A rapid compatibility test: the saline low ionic crossmatch. AABB 
30th Ann Mtg Abstract, 1977, p 8. 

Medications and Driving Performance 

Many people who take medica- 
tions prescribed by their physician 
drive automobiles. Of the 50 most 
commonly prescribed drugs in this 
country, 13 are antidepressants or 
tranquilizers, whose recognized ac- 
tion is to affect the brain and nerv- 
ous system. When these drugs 
function to improve psychological 
tolerance of an individual, they have 
a good effect. However, these drugs 
may have a bad effect on driving 

Other common drugs, whether 
prescribed by a physician or pur- 
chased "over the counter," may 
also adversely affect driving ability. 
Examples include antihistamines 
and "cold pills," as well as gastro- 

intestinal and cardiac drugs. 

When tested under laboratory 
conditions, ordinary doses of drugs 
often have little or no effect on driv- 
ing performance. However, one 
must remember that these tests are 
done in a contrived situation that 
may bear little resemblance to real- 
life conditions. The experimental 
subjects are usually well-rested, are 
not ill, and receive a single dose as 
opposed to long-term repeated 
doses. There may be an entirely dif- 
ferent result when a person is driv- 
ing home on the freeway after a tir- 
ing workday, sustained by a tran- 
quilizer. Driving-performance tests 
indicate two important effects of 
some drugs: (1) drugs may adverse- 

ly affect some functions of driving; 
(2) experimental subjects were un- 
aware that their driving was being 

It would not be justified to say 
that people who drive should not 
take drugs; single drugs may main- 
tain the individual in better condi- 
tion to drive. However, drivers 
should be aware that drugs may im- 
pair their ability to operate a motor 
vehicle. They should judge whether 
or not they want to drive on a spe- 
cific occasion on the basis of 
whether they need to do so and of 
the other factors involved. Drugs 
can be an important risk to drivers, 
but commonsense precautions can 
greatly reduce that risk. 

Volume 69, October 1978 



A Behavioral Treatment of Nocturnal Enuresis 

LT Michael R. Marcy, MSC, USNR 

LTJohn B. Hopkins, MSC, USNR 

LT Mark D. Cunningham, MSC, USNR 

It is well to begin consideration of this topic with a 
brief definition of the disorder and data concerning its 

Nocturnal enuresis, or simply enuresis, is commonly 
defined as the involuntary discharge of urine, during 
sleep, by individuals who are more than three or four 
years old and have no demonstrable organic pathology. 

On the basis of enuretic patients' history of bed- 
wetting, they are commonly divided into two major 
groups: primary and secondary enuretics. The "pri- 
mary" classification is reserved for patients who have 
never become continent, while in "secondary" 
enuresis the child resumes bed-wetting after a period of 
continence. This diagnostic classification appears to 
exist purely for descriptive purposes and has not been 
found to have any prognostic validity (1). 

Nocturnal enuresis is a significant pediatric problem 
that is found in approximately 20% of all 5-year-olds. 
This percentage gradually decreases with maturation to 
approximately 2% at age 14 (2). The disorder occurs 
more frequently in males than in females, by a ratio of 
approximately 2:1 (1). Since nocturnal enuresis is such 
a prevalent disorder, any pediatric practitioner is likely 
to encounter a large number of enuretic patients. 

The treatment modalities for functional enuresis are 
varied and range from medication, such as imipramine, 
to psychodynamic psychotherapy to behavioral tech- 

LT Marcy is a clinical psychology intern of the Psychiatry Service, 
National Naval Medical Center, Bethesda, Md. 20014. 

LT Hopkins is a clinical psychologist at Marine Corps Recruit 
Depot, Parris Island, S.C. 29905. 

LT Cunningham is a clinical psychologist at Naval Submarine Cen- 
ter, New London, Conn. 06340. 

Medical treatments, including imipramine, have 
often been criticized because of an extremely high in- 
cidence of relapse following withdrawal from the drug 
(3,4) and because of potential side effects such as diz- 
ziness, sleeplessness, irritability, and poisoning (5,6). 

Psychotherapy, as a treatment for enuresis, has been 
criticized from an even more important standpoint, i.e., 
that it has no significant effect in reducing the symptom 

Of the behavioral treatments, the most successful 
and well-known is the pad-and-buzzer conditioning 
system described by Mowrer and Mowrer (8). Briefly, 
the Mowrer-type instrument consists of a urine-sensi- 
tive pad on which the patient sleeps. When the child 
micturates, urine passes onto the pad and activates a 
bell or buzzer. The alarm awakens the child, who 
ceases voiding, disconnects the alarm, and initiates 
micturition in the toilet. Eventually, the arousal re- 
sponse that initially was produced by the alarm pre- 
cedes micturition. Arousal comes to be produced by 
stimuli such as those provided by the distended blad- 

Lovibond (7) attributed the coupling of the arousal 
response and the appropriate physical stimuli to oper- 
ant conditioning. Essentially, arousal that occurs before 
an enuretic event allows the patient to avoid an aversive 
stimulus, the alarm. In this way elimination of the 
enuretic symptom is reinforced. 

A complete and detailed description of the Mowrer- 
type apparatus and treatment procedure may be found 
in Dische (9) and Turner (10). 

Investigators have reported several advantages of 
the pad-and-buzzer system over other treatment 
methods. The system has been found to be preferable 
to medication because of the relative absence of side 
effects and the lower rate of relapse (11). It is also pref- 


U.S. Navy Medicine 

erable to psychotherapy, since it typically requires sig- 
nificantly less professional time in administration and is 
of demonstrated effectiveness (2). In fact, the Mowrer- 
type instrument has been reported to be more effica- 
cious than either medical or psychodynamic approaches 

The present study is an initial evaluation of a behav- 
ioral enuresis treatment program utilizing the Mowrer- 
type alarm system. The program has been conducted 
by the Psychology Division of the Psychiatry Service, 
National Naval Medical Center, Bethesda, Md., with 
support in the form of medical expertise provided by 
the Pediatric Service. 


Patients were referred to the enuresis clinic only 
after a complete medical workup by the Pediatric Ser- 
vice to rule out the possibility of organic etiology. Upon 
referral, patients were placed on a waiting list until a 
pad-and-buzzer system became available. The appara- 
tus used in the National Naval Medical Center clinic 
was the "Wee Alert," distributed by Sears, Roebuck 
and Company, although equally effective systems are 
available elsewhere. 

When an apparatus became available, the patient 
and at least one parent were consulted and verbally in- 
structed in its use. The system was assembled in the 
office, the buzzer was sounded, and both the child and 
the parent were given a brief explanation of how the 
apparatus worked. 

The emphasis of the office visit was on making the 
family more comfortable with the disorder. Each child 
was told that many children have the problem of bed- 
wetting, and that it is not something a child or a parent 
should worry about. It was indicated that sooner or later 
the child would be able to sleep dry, but that the pad- 
and-buzzer system was designed to help him do it more 

Each patient was told that the system would work 
because it would arouse him while he was wetting, and 
that he would be able to develop greater sensitivity to 
the physiological cues received as his bladder became 
full. The success of the program was presented as 
being dependent on the child's utilization of capabilities 
in his possession. It was explained that the apparatus 
would give the child the opportunity to learn to use 
these capabilities. This explanation coupled success in 
the program with a sense of personal accomplishment 
for the child. 

Parents were advised to respond to the buzzer in 
order to help arouse the child, be sure that he went to 
the toilet, and assist in remaking the bed and resetting 
the alarm. Parents were asked to be supportive during 
these nocturnal episodes, and any exchange between 
parent and child that would contribute to the unpleas- 
antness of the situation was frankly discouraged. 

Each parent was provided with a written set of in- 
structions, a report card on which to record the child's 

progress, and a booklet containing a series of com- 
monly asked questions and answers concerning 
enuresis. This written material completely specified the 
procedures and rationale involved in the program and 
served as reference for all information covered in the 
office visit. 

Patients were advised to follow the procedure nightly 
until they had passed 21 consecutive dry nights. 
Parents were instructed to telephone the clinic to report 
on progress after two weeks and at any other time they 
desired consultation. Telephone contact was important 
in that it facilitated identification of potential problems 
and allowed the psychologist to give much-needed en- 
couragement when progress was slow. 

Typically, progress was noted in two to three weeks, 
and the program was completed in five to ten weeks. 

Followup was obtained on 50 patients (33 males, 17 
females) and six untreated control subjects (3 males, 3 
females). Untreated and treated subjects were compa- 
rable in all relevant respects. Ages ranged from 4 to 19 
years and averaged 9.02 years. Subjects' frequency of 
enuresis, at the time of referral, varied from once per 
week to several times nightly. In our sample, 45 sub- 
jects were primary enuretics and 11 were secondary 

Followup information was obtained via telephone 
interview and included demographic data, enuresis 
history, family data, and a parental attitude rating. 
Length of followup ranged from 3 to 43 months and 
averaged 20.13 months. 


The parental attitude rating of the program clearly 
indicated that parents were generally pleased with it. 
Eighty percent of the parents interviewed rated the 
program successful, while only 20% rated it unsuccess- 
ful. A few parents remarked that the program had 
importantly affected their children's lives in terms not 
only of decreased enuresis, but of increased self- 
esteem and confidence. These parents could not find 
enough superlatives to describe their attitudes toward 
the procedure. 

In no case did we have a report of a significant nega- 
tive side effect. 

A more objective measure of success was whether or 
not patients were able to achieve the 21 consecutive dry 
night criterion. Of those parents interviewed, 72% 
indicated that their children reached the criterion, 
while only 28% reported that their children were 
unable to do so. Reaching criterion represented a 
significant improvement, since the patients had an 
average initial enuresis frequency of 5.45 wet nights 
per week. 

For any treatment of problem behavior, the two most 
important indications of success are the extent to which 
the treatment decreases the behavior and the percent- 
age of patients in which it does so. The present treat- 
ment program decreased the frequency of enuresis in 

Volume 69, October 1978 


76% of the patients, with a mean decrease of 3.93 wet 
nights per week. Total remission was reported by 50% 
of the patients. The latter percentage becomes more 
meaningful when it is noted that of the eight relapses 
reported during followup, seven occurred in the first 
three months after the end of treatment. Thus, those 
patients who reported no further enuresis during our 
followup were actually past the time when relapse is 
most likely. 

A question might be raised as to whether the success 
experienced by our patients was a result of treatment or 
of maturation, since it is well established that enuresis 
decreases with time. To resolve this question, a "Stu- 
dent's" ttest, assuming homogeneity of error variance, 
was used to test the hypothesis that the decrease in 
enuresis in the treated patients was not significantly 
greater than the decrease in the untreated control sub- 
jects. The tenability of the assumption of homogeneity 
of variance was supported by a Hartley's F max test 
CF max = 1.15, P>.25), For patients treated with the 
pad and buzzer, the mean decrease in enuresis from 
time of referral to time of followup (3.93 fewer wet 
nights per week) was significantly greater than the de- 
crease for the no-treatment control subjects: 1.17 fewer 
wet nights per week (l 54 = 3.53, P< .001). Thus, the 
treatment condition decreased enuretic behavior signif- 
icantly more than the no-treatment condition, although 
enuresis in the control subjects also decreased in fre- 

In our study, data was also collected to attempt to 
delineate possible prognostic signs. The following 
nominal variates were analyzed: primary versus sec- 
ondary enuresis; successful prior therapy for enuresis 
versus unsuccessful prior treatment versus no prior 
therapy; enuresis history in the immediate family 
versus no other enuresis history in the family; sex; 
presence of other physical illness versus presence of 
other mental illness versus no other remarkable illness; 
parental divorce or separation versus no divorce or 

Among the groups delineated, we found no signifi- 
cant difference in response to treatment. No prognostic 
value was identified in the nominal variates studied. No 
factor studied could be used to rule out the use of this 
behavioral treatment modality because of decreased 
likelihood of effectiveness. 


Our data conclusively demonstrated that the pad- 
and-buzzer apparatus effectively treated nocturnal 
enuresis, in terms of decreased frequency, when 
treated subjects were compared with an untreated con- 
trol group. In fact, 50% of our patients did not experi- 
ence an enuretic event between termination of treat- 
ment and followup. The positive effects of treatment 
are also attested to by the fact that the great majority 
(80%) of parents had very positive attitudes toward the 
program. Some suggested that the treatment not only 

decreased their children's enuresis but also produced 
positive personality effects, such as increased con- 
fidence and self-esteem. These positive personality 
effects probably resulted from explanation to the 
patients that the procedure's success would depend on 
use of their own capabilities. There was no report of a 
negative side effect or of symptom substitution. 

It is clear that this treatment method, which utilized 
the skills of both pediatricians and psychologists in a 
combined effort, produced a high degree of treatment 

Our data corroborate previous research findings con- 
cerning the lack of prognostic validity of the primary 
versus secondary dichotomy. In addition, none of the 
other factors we studied differentiated response to 
treatment. None of these factors — including sex, family 
enuresis history, illness, parental separation, and 
history of prior enuresis therapy — could be used to rule 
out the use of the pad-and-buzzer system because of 
diminished likelihood of effectiveness. 

In sum, at the National Naval Medical Center, the 
Mowrer-type conditioning instrument has proven to be 
a useful treatment of nocturnal enuresis. The treatment 
not only has efficacy but also rarely causes side effects, 
requires a minimum of professional time, acts relatively 
rapidly, and has a low incidence of relapse. These 
qualities clearly indicate the superiority of the pad-and- 
buzzer system over either medication or psychotherapy 
in the treatment of enuresis. 


1. Doleys DM: Behavioral treatments for nocturnal enuresis in 
children: a review of the recent literature. Psychol Bull 84:30-54, 

2. Lovibond SH, Coote MA: Enuresis, in Costello CG (ed): Symp- 
toms of Psyckopathology: A Handbook. New York: Wiley and Sons, 

3. Bostock J: The deep sleep-enuresis syndrome. Med J Aust 
49:240-243, 1962. 

4. Munster AJ, Stanley AM, Saunders JC: Imipramin (Tofranil) 
in the treatment of enuresis. Am J Psychiatry 118:76-77, 1961. 

5. Blackwell B, Currah J: The psychopharmacology of nocturnal 
enuresis, in Kolvin I, MacKeith RC, Meadow SR (eds): Bladder Con- 
trol and Enuresis. Philadelphia: J. B. Lippincott Co., 1973. 

6. Parkin JM, Fraser MS: Poisoning as a complication of 
enuresis. Dev Med Child Neurol 14:727-730, 1972. 

7. Lovibond SH: Conditioning and Enuresis. Oxford, England: 
Pergamon Press, 1964. 

8. Mowrer OH, Mowrer WA: Enuresis: a method for its study 
and treatment. Am J Orthopsychiatry 8:436-447, 1938. 

9. Dische S: Treatment of enuresis with an enuresis alarm, in 
Kolvin I, MacKeith RC, Meadow SR (eds): Bladder Control and 
Enuresis. Philadelphia: J. B. Lippincott Co., 1973. 

10. Turner RK: Conditioning treatment of nocturnal enuresis, in 
Kolvin I, MacKeith RC, Meadow SR (eds): Bladder Control and 
Enuresis. Philadelphia: J. B. Lippincott Co., 1973. 

11 . Young GC: Conditioning treatment of enuresis. Dev Med Child 
Neurol 7:557-562, 1965. 

12. Jones HG: The behavioral treatment of enuresis nocturna, in 
Eysenck HJ (ed): Behavior Therapy and the Neuroses. Oxford, 
England: Pergamon Press, 1960. 

13. Yates AJ: Behavior Therapy. New York: Wiley and Sons, 


U.S. Navy Medicine 



Health Research Center, San Diego, has developed and 
tested a portable counterimmunoelectrophoresis field 
kit for rapid diagnosis of meningococcal meningitis, 
streptococcal infections, and pneumococcal pneumonia. 
The kit provides a simplified system of rapid diagnostic 
bacteriology for Navy shipboard, field, and small-dis- 
pensary use. The unit has twice been tested in Africa 
for the specific diagnosis of cerebral meningitis, at the 
request of, and in cooperation with, the World Health 

first six months of 1978, the Army-Navy Organ Trans- 
plant Service, located at Walter Reed Army Medical 
Center, performed more than 20 renal transplants and 
procured more than 30 cadaveric kidneys. Residents in 
urology and surgery from WRAMC, the National Naval 
Medical Center, and NRMC Portsmouth, Va., have 
greatly benefited from this increased exposure to the 
problems of transplantation. 

At the Naval Medical Research Institute, Bethesda, 
Md., the Organ Preservation Laboratory has begun 
new investigations into normothermic organ preserva- 
tion, vascular prostheses, plasminogen activators, and 
graft rejection. On the clinical side, the organ preserva- 
tion team has the capability of procuring donor organs 
anywhere in CONUS and has obtained three times the 
number of kidneys that were procured for transplanta- 
tion in FY 1978. 

GRAMS SOUGHT . . . Officers desiring teaching posi- 
tions in Navy residency training programs should sub- 
mit curricula vitae to BUMED Code 31 to ensure that 
their most recent achievements are properly reviewed 
and recorded. 

In this respect, all commanders and captains are en- 
couraged to submit curricula vitae as changes take 
place in their career and professional development. 

Corps lieutenant commanders in the zone for com- 
mander have a better chance of advancement, thanks to 
a recent change from an 80% to a 90% promotion 
opportunity. The change will be implemented for the 
FY 1979 selection board, which convenes 31 Oct 1978. 

HALOTHANE WARNING . . . Abuse and unauthorized 
use of the anesthetic halothane has resulted in the 
deaths of six Navy personnel in the last three years. 

There is a great risk of cardiac arrhythmia and arrest 
when this drug is inhaled from a plastic bag, gauze 
sponge, bottle, or other makeshift container. Receipt, 
storage, and issuing of halothane, which is a controlled 
drug, should comply with Chapter 21 of the Manual of 
the Medical Department. Ships having halothane not 
authorized by the Authorized Medical Allowance List 
should destroy or turn it in at the nearest Navy medical 
facility ashore. 

MOHCATs ORDERED ... To improve delivery of 
audiometric testing services to the fleet and operational 
units, BUMED has begun procurement of an initial four 
mobile hearing conservation and audiometric trailers 

The MOHCAT has successfully completed pilot- 
project evaluation at NRMC Charleston, S.C. Each 
trailer is a self-contained audiometric testing facility 
that can be towed into position near the unit or activity 
to be served. The trailers are expected to augment cur- 
rent audiometric facilities that are now frequently over- 
loaded, and to reduce the loss of productive man-hours 
entailed when crewmen or civilian workers must report 
for hearing tests to a fixed, distant medical facility. 

Initial plans call for procurement of 18 MOHCATs 
over a five-year period. 

AUDIT TD?S . . . The following discrepancies were 
noted on a recently completed audit: 

• Establishing an internal review function. Com- 
mand should establish an internal review function to 
ensure that procedures have been implemented to safe- 
guard the financial integrity of the command, and to 
ensure that all available command resources are effec- 
tively utilized (SECNAVINST 7510.8). 

• Reviewing the ODCR. There is a lack of adequate 
control over the timely and correct reporting of informa- 
tion into the MAPMIS. The Officer Distribution Control 
Report (ODCR), which is prepared monthly from 
MAPMIS data and forwarded to all activities, is not re- 
viewed for accuracy. Command should ensure that 
personnel actions are reported correctly, in a timely 
manner; review the monthly ODCR upon receipt; and 
report inaccuracies to SUPERS for correction. 

• Accounting for identification cards. The BUPERS 
Manual provides procedures to account for Armed Ser- 
vices Identification Cards (DD Form 2N), including a 
record of issuance in a permanent log and documenta- 
tion of issuance in the recipient's service record. NAV- 
REGMEDCEN must control and document issuance of 
identification cards in accordance with Article 4621050 
of the BUPERS Manual. 

Volume 69, October 1978 

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